AIDS
EPIDEMIOLOGY AND SOCIAL
State-level structural sexual stigma and HIV prevention in a national online sample of HIV-uninfected MSM in the United States
Oldenburg, Catherine E.a; Perez-Brumer, Amaya G.b; Hatzenbuehler, Mark L.b; Krakower, Douglasc; Novak, David S.d; Mimiaga, Matthew J.a,e,f; Mayer, Kenneth H.c,e,g
aDepartment of Epidemiology, Harvard School of Public Health, Boston, Massachusetts
bDepartment of Sociomedical Sciences, Columbia Mailman School of Public Health, New York, USA
cDivision of Infectious Diseases, Department of Internal Medicine, Beth Israel Deaconess Medical Center
dOLB Research Institute, Online Buddies, Inc., Cambridge
eThe Fenway Institute, Fenway Community Health
fDepartment of Psychiatry, Harvard Medical School/Massachusetts General Hospital
gDepartment of Global Health and Population, Harvard School of Public Health, Boston, Massachusetts, USA.
Correspondence to Catherine E. Oldenburg, MPH, 677 Huntington Ave, 9th Floor, Boston, MA 02115, USA. Tel: +1 510 684 9466; e-mail: [email protected]
Received 25 November, 2014
Revised 9 February, 2015
Accepted 9 February, 2015
Abstract
Background:
Stigmatizing social environments (of which ‘structural stigma’ is one component) negatively affect health-related outcomes. However, few studies have examined structural stigma related to sexual minority status as a risk factor for HIV outcomes among MSM.
Methods:
In August 2013, members of a large MSM social and sexual networking site in the United States completed a survey about HIV-prevention practices. A previously validated composite index provided values for state-level structural stigma, including density of same-sex couples, proportion of public high schools with Gay-Straight Alliances, state laws protecting sexual minorities, and public opinion toward homosexuality. Multivariable logistic generalized estimating equations assessed the relationship between structural stigma and condomless anal intercourse, use and awareness of antiretroviral-based HIV-prevention strategies (i.e. pre and postexposure prophylaxis, or PEP and PrEP), and comfort discussing male–male sex with primary care providers.
Results:
Among the 4098 HIV-uninfected MSM, lower state-level structural stigma was associated with decreased odds of condomless anal intercourse [adjusted odds ratio (aOR) 0.97 per one unit increase in structural stigma score, 95% confidence interval (CI) 0.94–0.99], increased odds of awareness of PEP (aOR 1.06, 95% CI 1.02–1.09), and PrEP (aOR 1.06, 95% CI 1.02–1.10), having taken PEP (aOR 1.15, 95% CI 1.05–1.26) and PrEP (aOR 1.21, 95% CI 1.01–1.44), and comfort discussing male–male sex with providers (aOR 1.08, 95% CI 1.05–1.11), after adjusting for social and state-level confounders.
Conclusion:
MSM living in more stigmatizing environments had decreased use of antiretroviral-based HIV-prevention strategies compared to those in less stigmatizing environments. Legal reforms protecting sexual minorities should be evaluated as structural interventions that could reduce HIV risk among MSM.